Medical Form Template

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How to Use the Medical Form Template

All <enclosed> words are entry fields- where you enter your patient information.

Diagnosis: In this section list out all medical diagnosis the patient has been given. This list will very with each patient. A lot of times when asked this on the spot it is hard to come up with everything (or the correct name). This will help to be sure you get them all.

Cerebral Palsy
Seizure Disorder

Allergies: Your doctor will go over the details of the allergic reaction, all you need to do here is indicate if there are any drug allergies and if so, the drug/medication that the patient is allergic to.


MAJOR Medical History: This is MAJOR Medical, not ALL medical (Hospital Stays, Procedures, Special Treatments, etc). The date may be a single date is if was an outpatient procedure or it may need to be a date range if it was a hospital admitition.

Date Location Summary
01/01/10 Dell Children’s Hospital Ear tubes placed
2/1/10-2/3/10 Seton Main Sleep Study
3/1/10-4/5/10 Austin HBOT Hyperbaric Treatments (40-1 hour sessions)

Nutrition: You may not need this section at all if you are not on a special diet or G-Tube. If so just enter N/A and move on to the next section.

This box is to enter the type(s) of formulas, if you do some oral some tube feeds, if you do bolus feed- enter those details here.
Rate/hr 50ml
Total daily goal 1200ml

Medications: Be sure to include all prescription as well as over the counter medications.

Some helpful abbreviations for frequency:

  • PRN indicates you take the medication as needed
  • BID is twice a day
  • TID is three times a day
  • QID is 4 times a day
  • Q# is every # hours ie: Q6 is every 6 hours.
Name Strength Dose Frequency
Motril 20/5MG 5ml PRN
Prevacid 15MG Solutab 1 tab BID
Keppra 100MG/ML SOLN 8ml Q8

Medical Providers: This area can cover many areas (doctors, therapists, DME, Pharmacies, etc). Depending on the patient you may have a lot of entries for this section.

Name Specialty Phone Notes
Dr. Jones Pediatrics (512)555-1234 RN-Jenny
CVS Pharmacy (512)555-2345
DCMC Outpatient Rehab (512)555-3456 PT – Joe
Travis Med DME (512)555-4567 Enteral Supplies
PSA Nursing (512)555-5678 Case Manager- Lynn

Equipment: In this section list out any medical equipment the patient uses. This can be a variety of things.

Name DME/Supplier
SuperStand Owned/Purchased
Zevex Infinity Pump ABC Medical Supply
DeVilBiss ABC Medical Supply
8french caths. Walgreens Home Health

Recent Labs, Imaging, Illnesses: In this section list out any recent labs, images and/or illnesses your child may have had. This really should just cover the past 6 weeks or less. This box my be better left blank and one you just write in on each visit if the rest of these sections are fairly stable for your child.

Labs drawn at Pedi request on 2/12/16 at American Labs, Chest Xray done in ER on 4/4/16 at Dell Childrens….